Below are the current versions of most common provider forms. Please check forms in your office to ensure your versions are the most up-to-date. To order a large supply of forms or to order materials not listed on this page, use the Iowa or South Dakota Provider Forms Order Form.

Be sure to contact your financial institution(s) to make certain they are aware of the CAQH CORE (Council for Affordable Quality Healthcare, Committee on Operating Rules for Information Exchange) EFT and ERA operating rules. The appropriate arrangements will need to be made between you and your financial institution to accommodate the delivery of the CORE required minimum CCD+ (Cash Concentration or Disbursement including an addenda record) Data Elements necessary for reassociation of the EFT payment with the ERA. CAQH CORE has developed a sample letter for providers to utilize when reaching out to their financial institutions. Access http://caqh.org/CORE_EFT_ERA.php for additional information pertaining to reassociation.

Network Participation Forms

All forms regarding network participation are available at our Credentialing and Contracting page. On our page, you will also find the Credentialing Submission Tracker where you are able to track the status of your applications, recredentialing submissions, and change requests.

Paper Claim Forms

Pharmacy Forms

Pharmacy Exception Requests for Non-Formulary MedicationsA non-formulary drug is a drug that is not covered under a prescription drug plan because cost-effective alternatives are available under the formulary drug coverage.

If you need to prescribe a non-formulary medication, complete the Exception Request form and fax it to the number on the form.

Note: This form is different than a prior authorization request, which allows Wellmark to verify a prescription drug is part of a specific treatment plan and is medically necessary.

Physical Medicine Form

Prior Approval Medical Forms

Prior Approval Form (To determine when to complete this form, visit Important Authorization Terms. These forms are only to be used for non-contracting or out-of-state providers. Contracting providers need to use the online Utilization Management Tool.)

Note: The post-service provider appeal process does not apply to overpayment recovery requests. If you have received an overpayment recovery request and do not agree with our reasons for requesting the refund, submit an overpayment recovery appeal.